1/4/2017 2017 CPC® Certification Review Copyright © 2017 AAPC 1 CPT® CPT® copyright 2016 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 2 1 1/4/2017 The Business of Medicine 3 Payers Self-Pay vs Insurance • Self-pay • Insurance • Private (commercial) insurance • BCBS • Aetna • Cigna • Government insurance • Medicare • Medicaid • TriCare 4 2 1/4/2017 Medicare Medicare Parts • Part A – Inpatient hospital care • Part B – Outpatient medical care • Part C – Medicare Advantage • Part D – Prescription drug coverage 5 RBRVS • Non-Facility Pricing Amount [(Work RVU * Work GPCI) + (Transitioned Non-Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * Conversion Factor (CF) • Facility Pricing Amount [(Work RVU * Work GPCI) + (Transitioned Facility PE RVU * PE GPCI) + (MP RVU * MP GPCI)] * CF 6 3 1/4/2017 Medical Necessity Services or supplies that: • are proper and needed for the diagnosis or treatment of your medical condition, • are provided for the diagnosis, direct care, and treatment of your medical condition, • meet the standards of good medical practice in the local area, and • aren’t mainly for the convenience of you or your doctor. www.cms.gov/apps/glossary 7 National Coverage Determinations • National Coverage Determinations (NCD) help to spell out CMS policies on when Medicare will pay for items or services • Each Medicare Administrative Carrier (MAC) is then responsible for interpreting national policies into regional policies • LCD’s only have jurisdiction within their regional area 8 4 1/4/2017 Advance Beneficiary Notice • Providers are responsible for obtaining an ABN prior to providing the service or item to a beneficiary. • The form must be filled out in its entirety as well as the cost to the patient and the reason why Medicare may deny the service • Only the approved Form CMS-R-131 is valid and the forms may not be altered 9 HIPAA • National standards for electronic health care transactions and code sets; • National unique identifiers for providers, health plans, and employers; • Privacy and Security of health data. 10 5 1/4/2017 HITECH • The Health Information Technology for Economic and Clinical Health Act • Promote the adoption and meaningful use of health information technology • Strengthened HIPAA • Patient audit trail 11 OIG Compliance Plan 1. Conduct internal monitoring and auditing. 2. Implement compliance and practice standards. 3. Designate a compliance officer or contact. 4. Conduct appropriate training and education. 5. Respond appropriately to detected offenses and develop corrective action. 6. Develop open lines of communication with employees. 7. Enforce disciplinary standards through well-publicized guidelines. http://oig.hhs.gov/fraud/PhysicianEducation/05compliance.asp 12 6 1/4/2017 ICD-10-CM Coding 13 ICD-10-CM Layout • Coding Conventions • Official ICD-10-CM Guidelines for Coding and Reporting • Index to Diseases and Injuries (Alphabetic Index) • Table of Neoplasms • Table of Drugs and Chemicals • Index to External Cause of Injuries • Tabular List 7 1/4/2017 Index to Diseases and Injuries: History History family (of) (see also History, personal (of)) alcohol abuse Z81.1 allergy NEC Z84.89 anemia Z83.2 arthritis Z82.61 asthma Z82.5 blindness Z82.1 cardiac death (sudden) Z82.41 carrier of genetic disease Z84.81 chromosomal anomaly Z82.79 Index to Diseases and Injuries: History Personal (of) (see also History, family (of)) abuse childhood Z62.819 physical Z62.810 psychological Z62.811 sexual Z62.810 adult Z91.419 physical and sexual Z91.410 psychological Z91.411 alcohol dependence F10.21 8 1/4/2017 Table of Neoplasms Primary Malignant Secondary situ in Ca Benign Uncertain Behavoir Unspecified Behavior Neoplasm Index Malignant Neoplasm, neoplastic C80.1 C79.9 D09.9 D36.9 D48.9 D49.9 abdomen, abdominal C76.2 C79.8- D09.8 D36.7 D48.7 D49.89 cavity C76.2 C79.8- D09.8 D36.7 D48.7 D49.89 organ C76.2 C79.8- D09.8 D36.7 D48.7 D49.89 viscera C76.2 C79.8- D09.8 D36.7 D48.7 D49.89 wall (see also Neoplasm, abdomen, wall, skin C44.509 C79.2- D04.5 D23.5 D48.5 D49.2 connective tissue C49.4 C79.8- - D21.4 D48.1 D49.2 skin C44.509 Table of Drugs and Chemicals Substance Poisoning,Accidental (unintentional) Poisoning,Intentional self-harm Poisoning,Assault Poisoning,Undetermined effect Adverse Underdosing 1-propanol T51.3X1 T51.3X2 T51.3X3 T51.3X4 --- --- 2-propanol T51.2X1 T51.2X2 T51.2X3 T51.2X4 --- --- 2, 4-D (dichlorophen- T60.3X1 T60.3X2 T60.3X3 T60.3X4 --- --- oxyacetic acid) 2, 4-toluene dilsocyanate T65.0X1 T65.0X2 T65.0X3 T65.0X4 --- --- 2, 4, 5-T (trichloro- T60.1X1 T60.1X2 T60.1X3 T60.1X4 --- --- phenoxyacetic acid) 14-hydroxydihydro- T40.2X1 T40.2X2 T40.2X3 T40.2X4 T40.2X5 T40.2X6 morphinone. A ABOB T37.5X1 T37.5X2 T37.5X3 T37.5X4 T37.5X5 T37.5X6 Abrine T62.2X1 T62.2X2 T62.2X3 T62.2X4 --- --- Abrus (seed) T62.2X1 T62.2X2 T62.2X3 T62.2X4 --- --- Absinthe T51.0X1 T51.0X2 T51.0X3 T51.0X4 --- --- beverage T51.0X1 T51.0X2 T51.0X3 T51.0X4 --- --- Acaricide T60.8X1 T60.8X2 T60.8X3 T60.8X4 --- --- 9 1/4/2017 ICD-10-CM Layout External Cause of Injuries Index • External cause codes describe Fall, falling (accidental) W19- how an injury occurred building W20.1- • Read the notes at the beginning of burning (uncontrolled fire) X00.3- ICD-10-CM Chapter 20 External down Causes of Morbidity embankment W17.81- • NEVER primary escalator W10.0- hill W17.81- ladder W11- ramp W10.2- stairs, steps W10.9- ICD-10-CM Layout Tabular List of Diseases and Injuries 1. Certain Infectious and Parasitic Diseases (A00-B99) 2. Neoplasms (C00-D49) 3. Disease of Blood and Blood-Forming Organs and Certain Disorders Involving the Immune Mechanism (D50-D89) 4. Endocrine, Nutritional and Metabolic Diseases (E00-E89) 5. Mental, Behavioral and Neurodevelopmental Disorders (F01-F99) 6. Diseases of Nervous System and Sense Organs (G00-G99) 7. Diseases of the Eye and Adnexa (H00-H59) 8. Diseases of the Ear and Mastoid Process (H60-H95) 9. Diseases of the Circulatory System (I00-I99) 10. Diseases of the Respiratory System (J00-J99) 11. Diseases of the Digestive System (K00-K99) 12. Diseases of the Skin and Subcutaneous Tissue (L00-L99) 13. Diseases of the Musculoskeletal System and Connective Tissue (M00-M99) 14. Diseases of the Genitourinary System (N00-N99) 15. Pregnancy, Childbirth, and the Puerperium (O00-O99) 16. Certain conditions Originating in the Perinatal Period (P00-P99) 17. Congenital Malformations, Deformations, and Chromosomal Abnormalities (Q00-Q99) 18. Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (R00-R99) 19. Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88) 20. External Causes of Morbidity (V00-Y99) 21. Factors Influencing Health Status and Contact with Health Services (Z00-Z99) 10 1/4/2017 Coding Conventions and Guidelines Overview • Conventions for the ICD-10-CM • Official ICD-10-CM Guidelines for Coding and Reporting 21 Coding Conventions Index to Diseases and Injuries: Abbreviation NOS Sinusitis (accessory) (chronic) (hyperplastic) (nasal) (nonpurulent) • Not otherwise specified (purulent) J32.9 • Lacks information to use a more specific code Tabular List: J32.9 Chronic sinusitis, unspecified Sinusitis (chronic) NOS 11 1/4/2017 Coding Conventions Pneumonia (acute) (double) (migratory) (purulent) Parentheses (septic) (unresolved) J18.9 with • Enclose supplementary lung abscess J85.1 words due to specified organism – see Pneumonia, in (due to) • Nonessential modifiers influenza – see influenza, with, pneumonia adenoviral J12.0 adynamic J18.2 alba A50.04 allergic (eosinophilic) J82 alveolar – see Pneumonia, lobar anaerobes J15.8 anthrax A22.1 Coding Conventions With Diabetes, diabetic (mellitus) (sugar) • Means “associated with” or E11.9 “due to” when it appears in with amyotrophy E11.44 a code title, the Alphabetic arthropathy NEC E11.618 Index, or an instructional autonomic (poly)neuropathy E11.43 note in the Tabular List. cataract E11.36 • Presumed causal Charcot's joints E11.610 Chronic kidney disease E11.22 relationship between the main term and the terms listed under the entry “with.” 12 1/4/2017 ICD-10-CM Official Guidelines for Coding and Reporting Section I. Conventions, General Coding Guidelines and Referencing the Guidelines Chapter Specific Guidelines A. Conventions for the ICD-10-CM • Guidelines found at 1. The Alphabetic Index and Tabular List 2. Format and Structure beginning of the 3. Use of codes for reporting purposes ICD-10-CM codebook 4. Placeholder character 5. 7th Characters 6. Abbreviations a. Alphabetic Index abbreviations b. Tabular List abbreviations 7. Punctuation 8. Use of “and” 9. Other and Unspecified codes 25 ICD-10-CM Official Guidelines for Coding and Reporting Referencing the Guidelines • A documented reference appears as Section I.C.4.a.2. • This indicates the guideline is found in: • Section I. Conventions, General Coding Guidelines and Chapter Specific Guidelines • Section I.C. Chapter-Specific Coding Guidelines • Section I.C.4. Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00- E89) • Section I.C.4.a. Diabetes mellitus • Section I.C.4.a.2. Type of diabetes not documented 26 13 1/4/2017 ICD-10-CM Official Guidelines for Coding and Reporting Guideline Reference: I.C.4.a.2. Section I. Conventions, General Coding Guidelines and Chapter Specific Guidelines C. Chapter Specific Coding Guidelines 4. Chapter 4: Endocrine, Nutritional, and Metabolic Diseases (E00-E89) a. Diabetes mellitus The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.